Comparative Evaluation of Hypertension Prevention, Treatment and Control Efforts among Pilot and Non-pilot Health Facilities in Amhara Region, Northern Ethiopia, 2022: a Parallel Evaluation Design

Comparative Evaluation of Hypertension Prevention, Treatment and Control Efforts among Pilot and Non-pilot Health Facilities in Amhara Region, Northern Ethiopia, 2022: a Parallel Evaluation Design | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Evaluation of Hypertension Prevention, Treatment and Control Efforts among Pilot and Non-pilot Health Facilities in Amhara Region, Northern Ethiopia, 2022: a Parallel Evaluation Design Abiyie Demelash Gashe, Alefech Addisu, Dawit Zenebe, Aman Yusuf This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4686558/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background With increasing trends of hypertension, Ethiopia has been piloting hypertension program whose effectiveness was not ascertained yet. Therefore, this study aimed to determine effectiveness of pilot hypertension program in the Amhara region of Ethiopia. Methods We followed a parallel evaluation design to describe hypertension prevention, treatment and control efforts of four pilot and four non-pilot facilities in Amhara region from April 1–30, 2022. We used checklist with a structured questionnaire to collect data from record reviews, patient interviews and observations. Data were analyzed using SPSS version 25.0. The statistical comparison was made using chi-square test, t-test, 95% CI and p < 0.05. Result Pilot facilities demonstrated better performances in hypertension prevention (72.8% vs 43.6%), hypertension treatment (85.3% vs 55.0%) and hypertension control (49.8% vs 42.4%) domains. The rate of opportunistic blood pressure (BP) screening was higher in pilot facilities (91%) 95% CI: 87.8–93.5% than non-pilot facilities (74.4%), 95% CI: 71.2–79.7%. There was a statistically significant difference in hypertension detection rates between pilot facilities (19.9%), 95% CI: 16.2–24.0%) and non-pilot facilities (14.9%), 95% CI: 11.7–18.6%. Half (51.8%) of hypertensive patients in pilot and 42.4% in non-pilot facilities had controlled thier BP with a statistically significant difference between facilities, chi-square, X 2 = 0.823; p < 0.001. The mean performances across three domains was better in pilot facilities than non-pilot facilities (76.1% vs51.2%), t-test, t = 2.125; p = 0.042. Conclusion the evaluation of the pilot hypertension program in the Amhara region of Ethiopia has demonstrated promising results. Pilot facilities showed better performances across the three domains. They demonstrated better opportunistic BP screening, case detection and retention into care, and BP control compared to non-pilot facilities. Based on these findings, pilot hypertension program in the Amhara region should be scaled up into nationwide program and the successful components pilot program such as structured approach to hypertension management, protocol adherence, and integration of hypertension service into primary healthcare should be replicated. hypertension prevention hypertension treatment hypertension control pilot health facilities hypertension program evaluation Ethiopia Figures Figure 1 Figure 2 Background Globally, estimated 1.28 billion people have hypertension, with low-and-middle income countries (LMICs) sharing two-third to 80% of the global burden ( 1 – 2 ). It has been the leading modifiable cardio-metabolic risk factor for cardiovascular diseases (CVDs) ( 3 ). With a current trend, the prevalence of hypertension is expected to increase to 29% by 2025 ( 4 ). According to global health observatory report, 40% of adult’s ≥ 25 years have hypertension, with prevalence varying across income groups: 35% in high-income countries (HICs) and 40% in LMICs ( 5 ). In Sub-Saharan Africa (SSA), it has been reported up to 38% ( 6 ). In Ethiopia, based on the data from systematic review and meta-analysis, the pooled prevalence of hypertension was reported to be 21.8% ( 7 ), with wide variations across different settings: 9.3–30.3% in the population-based studies, 7–37% in the institution-based studies and 13.2–18.8% in the hospital-based studies ( 8 ). Non-communicable diseases (NCDs) including hypertension cost 31.3 billion Ethiopian Birr (ETB) ~ 559,000,000 United States Dollar (USD) each year, which is equivalent to 1.84% of the country’s Gross Domestic Product ( 9 ). Based on the findings from a study conducted in South Western Ethiopia, hypertension was associated with loss of 7,194 ETB (129 USD) out-of-pocket expenditure per month ( 10 ) Despite well-established approaches in diagnosis and treatment, the awareness, treatment and control of hypertension remained inadequate worldwide ( 11 ). According to May Measurement Month report, the global hypertension awareness, treatment, and control were 58.7%, 54.7% and 57.8%, respectively ( 12 ). In Ethiopia, 37–78% of hypertensive patients were not aware of their BP ( 8 ). Likewise, based on data from systematic review and meta-analysis, uncontrolled blood pressure (BP) was reported as high as 48% ( 13 ). Several hospital-based studies in the country also revealed BP control rates ranging 26.4–52.5% ( 13 – 17 ). The barriers to hypertension treatment and control exist at multiple levels: patient, healthcare provider and healthcare system levels ( 18 ). Patient related barriers to hypertension treatment and control include inadequate knowledge, limited access to essential medicines, non-adherence to medications and lifestyle factors. Healthcare provider related barriers consists non-compliance to treatment protocol, inadequate patient counseling, and lack of task sharing. Healthcare system barriers are those factors related to lack of policies, guidelines and limited financial protection mechanisms like health insurance schemes (18–21) To track NCDs, global communities were committed towards shared goals such as ‘reduce premature mortality from NCDs by one third by 2030’ ( 22 ) and ‘reduce prevalence of raised BP by 25% by the end of 2025’ ( 23 , 24 ). However, only few countries in the world are in a progress towards these goals ( 25 ) and African countries are off track, with results implying a lot to do in subsequent years ( 26 ). Furthermore, the World Health Organization (WHO) launched a Global Hearts Initiative including healthy lifestyle, evidence-based treatment protocols; access to essential medicines and basic technology; risk-based management; team based care and task-sharing; and systems for monitoring (HEARTS) technical packages to improve CVD management in primary healthcare settings and partnered with a Resolve to save lives (RTSL), initiative aimed to save 100 millions of lives from early and easily preventable deaths ( 2 , 27 , 28 ) In Ethiopia, the Federal Ministry of Health in collaboration with RTSL has been piloting hypertension program in primary healthcare settings ( 29 ). The program aimed for screening of 30% of eligible population and achieving 50% of BP control. The target population were adults’ ≥ 30 years of age. However, no evaluation has been conducted both national or sub-national levels, and the program’s effectiveness was not ascertained yet. Therefore, we aimed to evaluate hypertension prevention, treatment and control efforts among pilot facilities through a parallel evaluation design with non-pilot facilities and interested to answer a research question “did the differential investments in pilot health facilities brought a difference in hypertension prevention, treatment and control performances?” Methods Study setting A parallel evaluation design involving cross-sectional study was conducted at four pilot and four non-pilot facilities in the Amhara region, northern Ethiopia from April 1–30, 2022. Based on the 2007 census data, a total population of region for 2022 was estimated at 30 million. The study population were BP screening naive adults’ ≥ 30 years of age for prevention domain and known hypertensive patients on anti-hypertensive therapy for treatment and control domains. The study excluded those participants who refused to provide informed consent and/or whom BP related outcomes are incompletely recorded Sample size determination Sample size was estimated using double population proportion formula ( 30 ) and assuming power 80%, 95% CI, certainty (α = 5%), calculated margin of error (d = 0.045), hypertension treatment (P = 54.7%), and BP control (P = 50.4%) from the previous studies ( 16 , 19 ). Adding 10% compensation for incomplete data and/or response rate, sample size was 474. Sampling procedure The participant selection was conducted in the following way. First, we purposively included three Administrative Zones and two Metropolitan Cities piloting hypertension program in the region. Second, primary health facilities were stratified into pilot and non-pilot, and listed in each stratum. Third, two primary hospitals (Merawi and Addisalem Hospitals) and two health centers (Merawi and Addisfana health centers) from pilot, and two primary hospitals (Chagni and Durbete Hospitals) and two health centers (Injibara and Lideta health centers) from non-pilot facilities were randomly selected. Fourth, total sample size was proportionally allocated based on the probability proportional to size. Finally, using BP screening register, BP screening naive individuals were randomly selected from the register and subsequent evaluation of their records was conducted. Furthermore, known hypertensive patients on anti-hypertensive therapy who were available during the data collection period were consecutively recruited for an interview and consequently their charts were reviewed (Figure-1) Data collection Data were collected from participant interviews and/or record reviews; and observations using a checklist with a structured questionnaire. In collaboration with program evaluation and NCD program experts, indicators were developed from three domains of hypertension: prevention, treatment and control domains; and HEARTS implementation. Hypertension prevention domain addressed the opportunistic BP screening, confirmation and case detection practice, and retention into care. Treatment domain consisted healthcare providers adherence to treatment protocols, and patient awareness on anti-hypertensive therapy. Hypertension control domain encompassed the rate of BP control and patient adherence to healthy lifestyle. Finally, HEARTS implementation targeted to facility’s performances related to six packages: healthy lifestyle, evidence-based treatment protocols; access to essential medicines and basic technology; risk-based management; team based care and task-sharing; and systems for monitoring. We assessed BP measurement practices, healthcare provider’s adherence to treatment protocols and BP-related outcomes via record reviews. We assessed patient adherence to healthy lifestyle practice through face-to-face interview. Finally, the facility’s HEARTS package implementation was assessed using observation checklists carefully prepared according to the WHO HEARTS perspective. A total of four trained data collectors, experienced Bachelor of Science Degree nurses working on chronic follow-up units and two supervisors were participated in the data collection process Operational definitions Hypertension: patients presented with elevated systolic blood pressure (SBP) ≥ 140mmHg and/or diastolic blood pressure (DBP) ≥ 90mmHg were considered as hypertensive ( 31 ) Controlled BP: hypertensive patients who had achieved two successive BP readings of SBP < 140 mmHg and DBP < 90mmHg were considered to have controlled BP ( 32 ) Data quality control The questionnaire was pre-tested on 5% of the participants in the similar setup for its clarity, completeness and consistency. Data collectors were trained for three days regarding to data collection procedures and on how to safeguard data confidentiality during and after collection. Patient related questionnaire was translated into local language, Amharic then back to original English version. To account incomplete data, data collection tool was carefully designed in order to able to capture all relevant variables from the records. Finally, we employed completed case analysis for missing data, and cases having > 5% missing values were excluded from analysis. Data analysis Data were checked for completeness and consistency, coded, cleaned and analyzed using SPSS version 25.0. Descriptive statistics such as mean, standard deviations, median, interquartile range (IQR), proportions, tables and figures were used to summarize result. The independent t-test was performed to compare mean differences in performances of pilot and non-pilot facilities. Similarly, chi-square test was applied to depict association of HEARTS implementation between pilot and non-pilot facilities as well as BP control between pilot and non-pilot health facilities. Statistically, results were compared using p < 0.05 and 95% CI. Ethical considerations The study was approved by the Institutional Review Board of Amhara Public Health Institute (APHI) reference number NoH/R/T/T/D/5/21. Support letter was obtained from APHI, Hospitals and District Health Offices. The informed oral consent was obtained from each participant before commencement of the study. Data were de-identified, de-linked and stored in a secure file cabinet. Results Study characteristics This evaluation included eight primary health facilities; four pilots and four non-pilots from two Administrative Zones and one Metropolitan City in the Amhara region. For treatment and control domains, of 474 hypertensive patient-chart pairs involved in the study in each stratum, 422 in pilot facilities and 415 in non-pilot facilities met the inclusion criteria, response rate, 89% and 87.6% respectively. The median age of patients was 56 years, IQR 47-66 years in pilot facilities and 55 years, IQR 46-64 years in non-pilot facilities. Nearly half 421(50.3%) were females (Data not shown) The HEARTS Technical Packages implementation Healthy Life style All pilot (4/4) and all non-pilot (4/4) facilities had incorporated healthy lifestyle counseling practice into routine healthcare and used a standardized healthy lifestyle counseling tool. Half (2/4) of pilot and none (0/4) of non-pilot facilities had incorporated a routine NCD-related health education program in the morning sessions (Table 1) Evidence-based treatment All (4/4) pilot and none (0/4) of non-pilot facilities utilize the WHO’s hypertension diagnosis and treatment guideline. All pilot (4/4) and half (2/4) of non-pilot facilities use a standard case definition of hypertension. Furthermore, all (4/4) pilot facilities and none (0/4) of non-pilot utilize the major NCD treatment guidelines of Ethiopia (Table 1) Availability and affordability of core antihypertensive medications and technologies All (4/4) pilot and all (4/4) non-pilot facilities ensured the availability of essential anti-hypertensive medicines. Half of (2/4) pilot facilities and quarter of (1/4) non-pilot facilities were equipped with essential technologies including BP measuring apparatus and basic laboratory tests like renal function test, complete blood count, and lipid profile (Table 1) Risk-based management All pilot (4/4) and non-pilot facilities had incorporated CVD risk monitoring indicators in their reporting form as: low risk (< 10%), moderate risk (10-20%), high risk (20-30%) and very high risk (≥ 30%). The system to predict a 10-year CVD risk of a patient also existed in half of pilot and quarter of non-pilot facilities. The CVD risk treatment threshold was clearly indicated and delineated in all facilities (Table 1) Team care and task-sharing In half of pilot and non-pilot facilities, physicians initiate, refill, and update anti-hypertensive medications, assess the CVD risk and decide next appointment while non-physician health workers counsel patients, document relevant records, and compile and report data. Hypertension care was decentralized to the community level in all pilot facilities. Health extension workers were actively involved in lost to follow-up tracing and resuming care (Table 1) Systems for monitoring All pilot and non-pilot facilities had clear indicators to monitor BP control trends at three, six, 12, 24 and 36 months. However, all pilot and non-pilot facilities neither did analyzed the routine data nor did use it for action and response (Table-1) Hypertension prevention All (4/4) pilot and one-fourth of non-pilot facilities had incorporated the opportunistic BP screening practice for adults’ ≥ 30 years in the routine care. Three hundred eighty four (91%) of individuals in pilot facilities were screened thier BP 95% CI: 87.8–93.5%, which is significantly higher when compared to non-pilot facilities 314 (75.7%), 95% CI: 71.2–79.7%. One in five (19.9%), 95% CI: 16.2–24% of individuals screened for hypertension in pilot facilities and 14.9%, 95% CI: 11.7–18.6% in non-pilot facilities were confirmed to have hypertension (Figure 2) Hypertension treatment The initial antihypertensive medications were prescribed according to WHO protocol for 321 (76.1%), 95% CI: 71.7–80.1% of patients in pilot facilities and 295 (71.3%), 95% CI: 66.6–75.6% in non-pilot facilities, with a statistically significant difference in the protocol adherence between facilities. Likewise, there was a statistically significant difference in anti-hypertensive treatment intensification for patients between pilot facilities 349 (82.7%) 95% CI: 78.7–86.2% and non-pilot facilities 330 (77.8%) 95% CI: 73.5–81.7%. Moreover, patients in pilot facilities had better understanding of anti-hypertensive therapy (98.3% vs 96.1%) and its treatment target (59.5% vs 42%), chi-square test, p < 0.05 (Table 2) Hypertension control Three hundred fifty four (83.9%) of hypertensive patients in pilot facilities had reported never use of tobacco 95% CI: 80–87.3%, with no a statistically significant difference among patients in non-pilot health facilities 350 (84.5%), 95% CI: 80.7–87.9%. However, there was a statistically significant difference in avoidance of alcohol among patients in pilot facilities 345 (81.8%), 95% CI: 77.7–85.3% and those in non-pilot facilities 319 (77.1%), 95% CI: 72.7–81%. Moreover, the rate of BP control was better in pilot facilities 219 (51.9%), 95% CI: 47–56.8% than non-pilot facilities 179 (42.4%) 95% CI: 37.7–47.3% (Table 2) Effectiveness of hypertension prevention, treatment and control efforts The pilot facilities demonstrated better implementation of the WHO HEAERTS package than non-pilot facilities (75% vs 50.9%), chi-square test, X 2 =37.4; p < 0.001. The corresponding hypertension prevention, treatment and BP control performances among pilot and non-pilot facilities were 72.8%, 85.3% and 49.8%, and 43.6%, 55% and 42.7%, respectively. There was a statistically significant difference in mean performances of three domains between pilot and non-pilot facilities (76% vs 51.2%) t-test, t=2.13; p=0.042. Furthermore, pilot facilities demonstrated better BP control than non-pilot facilities, chi-square, X 2 =0.823; p < 0.001 (Table 3). Discussion We followed a parallel evaluation design to describe hypertension prevention, treatment and control efforts of four pilot and four non-pilot primary healthcare facilities in the Amhara region of Ethiopia and ascertain the effectiveness of pilot hypertension program. Pilot facilities demonstrated better implementation of the WHO HEARTS package than non-pilot facilities, chi-square test, X 2 = 37.4; p < 0.001. This could be explained by the fact that pilot facilities have received additional support, funding, and assistance from partners which could help the implementation of HEARTS packages. Additionally, pilot facilities may have benefited from a more supportive policy and regulatory environment for hypertension management. The opportunistic BP screening was higher in pilot facilities than non-pilot facilities, chi-square test, X 2 = 37.4; p < 0.001. Likewise, a significant difference was observed in hypertension case detection rates between facilities. Pilot facilities identified 19.9% of hypertensive cases, 95% CI: 16.2–24.0%, which is higher than hypertensive cases identified in non-pilot facilities 14.9%, 95% CI: 11.7–18.6%. Hypertension case detection rate in this study was consistent with findings from the opportunistic BP screening conducted in Coastal Karnataka (20.2%) ( 33 ) and India (17.9%) ( 34 ). However, it was lower than the findings from the opportunistic BP screening conducted in Nigeria (50.5%) ( 35 ) and Hong Kong (27.8%) ( 36 ). Furthermore, retention of hypertensive patients into care was higher in non-pilot facilities (92.8%) than non-pilot facilities (86.4%). This could be due to; pilot facilities may have more trained and dedicated staff in patient counseling and have better systems for patient tracking. The BP control rate was significantly higher in pilot facilities (51.8%) compared to non-pilot facilities (42.4%). The difference in BP control between facilities could be attributed due to difference in the WHO HEARTS package implementation. This result from pilot facilities showed that pilot facilities had achieved the milestone of Ethiopia’s pilot program i.e. achieving a 50% BP control. Moreover, BP control in this study was consistent with BP control in Ayder Comprehensive Hospital 52.5% ( 17 ) and Kenya 51.7% ( 37 ), lower than BP control in Canada 66% and USA 53% ( 38 ), and higher than BP control in SSA 8% ( 39 ), China 15% ( 40 ) and Italy 22.7% ( 41 ). The differences might be attributed by the difference in the study design and data collection, health system and socio-demographic and clinical characteristics of patients across different settings. Overall, in the present evaluation, pilot facilities demonstrated better performances across the three domains t-test, t = 2.125; p = 0.042. This could be explained by the fact that pilot facilities may have benefited from a more supportive policy and regulatory environment which ensures better access to essential medicines and basic diagnostics; and might have staffed with more trained health work force dedicated to facility’s goals to hypertension prevention, treatment and control compared to non-pilot facilities. Although this study had tried to better describe pilot program in the Amhara region through a parallel evaluation design, it has the following limitations. First, as this study was subject to Training Programs for Epidemiology and Public Health Interventions Network (TEPHINET) non-research proposal reminder, the data collection did not include detailed socio-demographic characteristics and other personal identifiable information. Hence, it did not examine the potential socio-demographic factors affecting BP-related outcomes. Second, the study is merely descriptive and quantitative. There is need for integration of qualitative approaches for better understanding potential impacts of pilot program in facility’s hypertension prevention, treatment and control effort Conclusion The pilot facilities demonstrated better performances in hypertension prevention, treatment, and control than non-pilot facilities. The mean performance across all the three domains was 76.1% in pilot facilities and 51.2% in non-pilot facilities (p = 0.042). The pilot facilities showed better opportunistic BP screening (91% vs 74.4%) and hypertension case retention (92.8% vs 86.4%) than non-pilot facilities (74.4%). Pilot health facilities achieved a 51.8% BP control rate, which is significantly higher than non-pilot facilities (42.4%) p < 0.001. The BP control rate in pilot facilities was consistent with other programs in Ethiopia, but lower than findings from high-income countries. The better performances of pilot facilities might be explained by a more comprehensive implementation of the WHO HEARTS packages including structured lifestyle counseling, evidence-based treatment protocols, improved availability of essential medications and technologies, and effective systems for team-based care and monitoring With these findings, we recommend that, a pilot hypertension program in the Amhara region of Ethiopia should be scaled up into nationwide so that the successful components of pilot program such as structured approach to hypertension management, protocol adherence, and integration of hypertension service into primary healthcare should be replicated if resources are available. Abbreviations BP blood pressure; APHI: Amhara Public Health Institute; CVDs: cardiovascular diseases; DBP: diastolic blood pressure; ETB: Ethiopian Birr; HEARTS: healthy lifestyle, evidence-based treatment protocols; access to essential medicines and basic technology; risk-based management; team based care and task-sharing; and systems for monitoring; HICs: high income countries; IQR: interquartile range; LMICs: low-and-middle income countries; NCDs: Non-communicable diseases; RTSL: Resolve to save lives; SBP: systolic blood pressure; SSA: Sub-Saharan Africa; TEPHINET: Training Programs for Epidemiology and Public Health Interventions Network; USD: United States Dollar; WHO: World Health Organization. Declarations Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board of Amhara Public Health Institute reference number NoH/R/T/T/D/5/21. The study also obtained informed oral consent from each participant before commencement of the study Consent for publication Not applicable Availability of data and materials The data sets and/or analyzed during the current study are available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests Funding The study was supported by grant, cooperative agreement or memorandum of agreement funded by the CDC foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of Abbott, the Task Force for Global health, Inc. or TEPHINET. Authors’ contributions Abiyie Demelash conceived the research idea, designed and conducted the study, analyzed the data, and drafted the manuscript. Dawit Zenebe provided substantial contributions to design of the study and drafting the article; Alefech Addisu conducted an extensive manuscript review and structuring. Aman Yesuf provided technical support during data analysis and interpretation, and drafting the manuscript. All authors read and approved the final manuscript. Acknowledgements Authors would like to acknowledge TEPHINET, cardiovascular disease small grant program for funding this study; Mekelle University, Ethiopian Field Epidemiology Training Program and Amhara Public Health Institute for their own contributions in fulfilling the legal and ethical procedures to conduct this study. We also like to thank Dr. Thompson-Paul from the Centers for Disease Prevention and Control Mentor for her continued guidance and mentoring of the study, and data collectors and supervisors participated in the study. References World Health Organization. Hypertension Key facts, 16 March 2023. Access on 20 May 2023 https://www.who.int/news-room/fact-sheets/detail/hypertension] . Schutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in low-and middle-income countries. 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Opportunistic Screening for Hypertension, Over-weight and Obesity among Companions of Patients Attending the Family Medicine Clinic of a Nigerian Tertiary Hospital. J Hypertens Manag. 2020;6:045. Li JT, Lam AS, Tomlinson B, Lee VW, May Measurement. Month 2017–2019: A Community-Wide Opportunistic Blood Pressure Screening Campaign in Hong Kong. Int J Hypertens. 2021;2021(1):8891794. Mohamed SF, Mutua MK, Wamai R, Wekesah F, Haregu T, Juma P, et al. Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya. BMC Public Health. 2018;18:1–0. Joffres M, Falaschetti E, Gillespie C, Robitaille C, Loustalot F, Poulter N, et al. Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study. BMJ open. 2013;3(8):e003423. Sorato MM, Davari M, Kebriaeezadeh A, Sarrafzadegan N, Shibru T, Fatemi B. Reasons for poor blood pressure control in eastern sub-Saharan Africa: looking into 4P’s (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review. BMC Cardiovasc Disord. 2021;21:1–5. Huang X, Liu L, Song Y, Gao L, Zhao M, Bao H, et al. Achieving blood pressure control targets in hypertensive patients of rural China–a pilot randomized trial. Trials. 2020;21:1–1. Tocci G, Ferrucci A, Pontremoli R, Ferri C, Rosei EA, Morganti A, et al. Blood pressure levels and control in Italy: comprehensive analysis of clinical data from 2000–2005 and 2005–2011 hypertension surveys. J Hum Hypertens. 2015;29(11):696–701. Tables Table 1: The WHO HEARTS package implementation among pilot and non-pilot facilities in Amhara region Sub-domains Indicators Pilot facilities (N=4) Non-pilot facilities (N=4) Yes No Yes No Healthy Life style Healthy lifestyle counseling 100% 0% 100% 0% Standardized counseling tool 100% 0% 100% 0% NCD-related health education 50% 50% 0% 100% Three month lifestyle adoption 100% 0% 100% 0% Evidence-based treatment Hypertension treatment protocol 100% 0% 0% 100% National hypertension guideline 50% 50% 50% 50% Standard BP measurement protocol 100% 0% 0% 100% Major NCD treatment guideline 75% 0% 0% 100% Case definition of hypertension 100% 0% 50% 50% Hypertension cohort register 100% 0% 0% 100% Availability and affordability of core antihypertensive medications and technologies Essential anti-hypertensive drugs 100% 0% 100% 0% availability, accessibility and affordability 100% 0% 100% 0% Basic technologies and diagnostics 75% 25% 25% 75% System to monitor essential drugs, basic technologies and diagnostics 100% 0% 50% 50% Risk-based management CVD risk stratification matrix 50% 50% 25% 75% CVD risk monitoring indicators 50% 50% 25% 25% CVD risk treatment threshold 100% 0% 100% 0% 10 year CVD risk prediction chart 50% 50% 0% 100% Referral system for intensive care 100% 0% 100% 0% Team based care and task-sharing Inter-professional treatment team 50% 50% 50% 50% Delineated responsibility 50% 50% 50% 50% Decentralized hypertension care 50% 50% 0% 100% Systems for monitoring Electronic data monitoring system 100% 0% 100% 0% CVD monitoring indicators 100% 0% 100% 0% Routine data analysis 0% 100% 0% 100% Use of data for action and response 0% 100% 0% 100% Table-2: Hypertension treatment and control efforts among pilot and non-pilot facilities, Amhara region, Northern Ethiopia, 2022 Domains Indicators Pilot facilities (N=422) Non-pilot facilities (N=415) Frequency (percent) 95% CI Frequency (percent) 95% CI Hypertension treatment Initial medicines prescribed as protocol 321 (76.1) 71.7–80.1% 296 (70.1) 66.6–75.6%. Medications intensified as per protocol 349 (82.7) 78.7–86.2% 322 (77.8) 73.5–81.7% Received all medicines in last visit 401 (95) 92.5–96.9% 403 (97.3) 95.3–98.7% Correct understanding of medication intake 415 (98.3) 96.6–99.3% 398 (96.1) 93.8–97.8% Know thier current BP 289 (68.5) 63.8–72.9% 273 (65.9) 61.2–70.5% Know target blood BP 251 (59.5) 54.6–64.2% 174 (42) 37.2–46.9% Aware of next follow-up 410 (97.2) 95.1–98.2% 403 (97.1) 95–98.1% Hypertension control Avoids tobacco smoking 354 (83.9) 80–87.3% 350 (84.5) 80.7–87.9% Avoids alcohol use 345 (81.8) 77.7–85.3% 319 (77.1) 72.7–81.0% Engages in exercise 115 (27.2) 23.1–31.8% 113 (27.3) 23.1–31.9% Practice healthy diet 273 (64.6) 59.9–69.3% 263 (63.5) 58.7–68.2% BP control 219 (51.9 47–56.8% 179 (42.4) 37.7–47.3% Table 3 : Comparison of hypertension prevention, treatment and control among pilot and non-pilot facilities in Amara region Domain Sub domains Indicators Pilot facilities Non-pilot facilities chi square test t- test Score Score HEARTS Implementations Healthy Life style 5 90% 60% X 2 =37.4 P < 0.001 Evidence-based treatment 6 79.2% 33.3% essential medications and technologies 4 93.8% 68.8% Risk-based management 5 70% 60% Team based care 3 66.7% 33.3% Systems for monitoring 4 50% 50% Mean score 27 75 ± 50 50.9 ± 20 Hypertension prevention, treatment and control Hypertension prevention 4 72.8 ± 25.5 43.6± 51.4 t=2.125 P= 0.042 Hypertension treatment 7 85.3± 18.2 55± 42.7 Hypertension control 5 49.8± 3 42.4% Mean score 16 76.1 ± 22.5 51.2± 42.1 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4686558","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":326959820,"identity":"7efba273-a615-4c50-b704-0d39158162bc","order_by":0,"name":"Abiyie Demelash Gashe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIie2PsWrDMBCGJdzVdBUEkicoNBREwcZ5kC4Shnjq3sFQGcP5IfoMXU1HG0G6mHp1cKDxG6RbvZReNJQscjoWqm8Qd3Afv35CHI6/CKOKCOLh5ClCVYgDzapfKvSorM1wRjHvj6LNOqlcPuXA9g/B/KrIso/xpY2eC40paXhnDdnVwEST3PCmzmd+08dlI1HZrO+VzekkMAlalp1UMwp9zCtU8IdWZWGUL/1Yvg/5OMJbzNthWrk2itKCdxSYD1XEuzMpy12d34pNssQKEPgQo4spYqLLvC+G7WcaLPir1tsRohVvk2F/SEN7fUIu2OkmzaWwnx/xDqfbavrY4XA4/iPfCoJvCD68kO8AAAAASUVORK5CYII=","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Abiyie","middleName":"Demelash","lastName":"Gashe","suffix":""},{"id":326959821,"identity":"809c373f-32b7-4954-8fe8-447085a4d802","order_by":1,"name":"Alefech Addisu","email":"","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Alefech","middleName":"","lastName":"Addisu","suffix":""},{"id":326959822,"identity":"af42e159-2ed2-4035-891d-2f883470a9d8","order_by":2,"name":"Dawit Zenebe","email":"","orcid":"","institution":"Mekelle University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dawit","middleName":"","lastName":"Zenebe","suffix":""},{"id":326959823,"identity":"913b7d08-b530-41a9-b606-105bb00a849a","order_by":3,"name":"Aman Yusuf","email":"","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aman","middleName":"","lastName":"Yusuf","suffix":""}],"badges":[],"createdAt":"2024-07-04 12:25:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4686558/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4686558/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62190497,"identity":"ad3526ff-b46f-4596-88a5-c983f1e1e0bb","added_by":"auto","created_at":"2024-08-10 12:28:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":55095,"visible":true,"origin":"","legend":"\u003cp\u003eThe sample selection scheme among pilot and non-pilot health facilities in Amhara region\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4686558/v1/5dde00d65d13c776237b3969.png"},{"id":62190496,"identity":"2d65b088-e372-4b1a-9003-bb3a87662124","added_by":"auto","created_at":"2024-08-10 12:28:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49470,"visible":true,"origin":"","legend":"\u003cp\u003eOpportunistic BP screening and hypertension detection practices among pilot and non-pilot facilities, Amhara region\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4686558/v1/d5bce9eaf149f39c701ab54e.png"},{"id":83288237,"identity":"d3a123d1-1a32-4472-8893-f1aa369a68c1","added_by":"auto","created_at":"2025-05-22 12:08:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":910594,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4686558/v1/b53671b5-6bf3-422e-b99c-d055bb50205d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Evaluation of Hypertension Prevention, Treatment and Control Efforts among Pilot and Non-pilot Health Facilities in Amhara Region, Northern Ethiopia, 2022: a Parallel Evaluation Design","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, estimated 1.28\u0026nbsp;billion people have hypertension, with low-and-middle income countries (LMICs) sharing two-third to 80% of the global burden (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). It has been the leading modifiable cardio-metabolic risk factor for cardiovascular diseases (CVDs) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). With a current trend, the prevalence of hypertension is expected to increase to 29% by 2025 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). According to global health observatory report, 40% of adult\u0026rsquo;s\u0026thinsp;\u0026ge;\u0026thinsp;25 years have hypertension, with prevalence varying across income groups: 35% in high-income countries (HICs) and 40% in LMICs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Sub-Saharan Africa (SSA), it has been reported up to 38% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Ethiopia, based on the data from systematic review and meta-analysis, the pooled prevalence of hypertension was reported to be 21.8% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), with wide variations across different settings: 9.3\u0026ndash;30.3% in the population-based studies, 7\u0026ndash;37% in the institution-based studies and 13.2\u0026ndash;18.8% in the hospital-based studies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Non-communicable diseases (NCDs) including hypertension cost 31.3\u0026nbsp;billion Ethiopian Birr (ETB)\u0026thinsp;~\u0026thinsp;559,000,000 United States Dollar (USD) each year, which is equivalent to 1.84% of the country\u0026rsquo;s Gross Domestic Product (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Based on the findings from a study conducted in South Western Ethiopia, hypertension was associated with loss of 7,194 ETB (129 USD) out-of-pocket expenditure per month (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite well-established approaches in diagnosis and treatment, the awareness, treatment and control of hypertension remained inadequate worldwide (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to May Measurement Month report, the global hypertension awareness, treatment, and control were 58.7%, 54.7% and 57.8%, respectively (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In Ethiopia, 37\u0026ndash;78% of hypertensive patients were not aware of their BP (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Likewise, based on data from systematic review and meta-analysis, uncontrolled blood pressure (BP) was reported as high as 48% (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Several hospital-based studies in the country also revealed BP control rates ranging 26.4\u0026ndash;52.5% (\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe barriers to hypertension treatment and control exist at multiple levels: patient, healthcare provider and healthcare system levels (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Patient related barriers to hypertension treatment and control include inadequate knowledge, limited access to essential medicines, non-adherence to medications and lifestyle factors. Healthcare provider related barriers consists non-compliance to treatment protocol, inadequate patient counseling, and lack of task sharing. Healthcare system barriers are those factors related to lack of policies, guidelines and limited financial protection mechanisms like health insurance schemes (18\u0026ndash;21)\u003c/p\u003e \u003cp\u003eTo track NCDs, global communities were committed towards shared goals such as \u0026lsquo;reduce premature mortality from NCDs by one third by 2030\u0026rsquo; (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and \u0026lsquo;reduce prevalence of raised BP by 25% by the end of 2025\u0026rsquo; (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, only few countries in the world are in a progress towards these goals (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and African countries are off track, with results implying a lot to do in subsequent years (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the World Health Organization (WHO) launched a Global Hearts Initiative including healthy lifestyle, evidence-based treatment protocols; access to essential medicines and basic technology; risk-based management; team based care and task-sharing; and systems for monitoring (HEARTS) technical packages to improve CVD management in primary healthcare settings and partnered with a Resolve to save lives (RTSL), initiative aimed to save 100 millions of lives from early and easily preventable deaths (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn Ethiopia, the Federal Ministry of Health in collaboration with RTSL has been piloting hypertension program in primary healthcare settings (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The program aimed for screening of 30% of eligible population and achieving 50% of BP control. The target population were adults\u0026rsquo; \u0026ge; 30 years of age. However, no evaluation has been conducted both national or sub-national levels, and the program\u0026rsquo;s effectiveness was not ascertained yet. Therefore, we aimed to evaluate hypertension prevention, treatment and control efforts among pilot facilities through a parallel evaluation design with non-pilot facilities and interested to answer a research question \u0026ldquo;did the differential investments in pilot health facilities brought a difference in hypertension prevention, treatment and control performances?\u0026rdquo;\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eA parallel evaluation design involving cross-sectional study was conducted at four pilot and four non-pilot facilities in the Amhara region, northern Ethiopia from April 1\u0026ndash;30, 2022. Based on the 2007 census data, a total population of region for 2022 was estimated at 30\u0026nbsp;million. The study population were BP screening naive adults\u0026rsquo; \u0026ge; 30 years of age for prevention domain and known hypertensive patients on anti-hypertensive therapy for treatment and control domains. The study excluded those participants who refused to provide informed consent and/or whom BP related outcomes are incompletely recorded\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample size determination\u003c/h2\u003e \u003cp\u003eSample size was estimated using double population proportion formula (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and assuming power 80%, 95% CI, certainty (α\u0026thinsp;=\u0026thinsp;5%), calculated margin of error (d\u0026thinsp;=\u0026thinsp;0.045), hypertension treatment (P\u0026thinsp;=\u0026thinsp;54.7%), and BP control (P\u0026thinsp;=\u0026thinsp;50.4%) from the previous studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Adding 10% compensation for incomplete data and/or response rate, sample size was 474.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling procedure\u003c/h2\u003e \u003cp\u003eThe participant selection was conducted in the following way. First, we purposively included three Administrative Zones and two Metropolitan Cities piloting hypertension program in the region. Second, primary health facilities were stratified into pilot and non-pilot, and listed in each stratum. Third, two primary hospitals (Merawi and Addisalem Hospitals) and two health centers (Merawi and Addisfana health centers) from pilot, and two primary hospitals (Chagni and Durbete Hospitals) and two health centers (Injibara and Lideta health centers) from non-pilot facilities were randomly selected. Fourth, total sample size was proportionally allocated based on the probability proportional to size. Finally, using BP screening register, BP screening naive individuals were randomly selected from the register and subsequent evaluation of their records was conducted. Furthermore, known hypertensive patients on anti-hypertensive therapy who were available during the data collection period were consecutively recruited for an interview and consequently their charts were reviewed (Figure-1)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData were collected from participant interviews and/or record reviews; and observations using a checklist with a structured questionnaire. In collaboration with program evaluation and NCD program experts, indicators were developed from three domains of hypertension: prevention, treatment and control domains; and HEARTS implementation. Hypertension prevention domain addressed the opportunistic BP screening, confirmation and case detection practice, and retention into care. Treatment domain consisted healthcare providers adherence to treatment protocols, and patient awareness on anti-hypertensive therapy. Hypertension control domain encompassed the rate of BP control and patient adherence to healthy lifestyle. Finally, HEARTS implementation targeted to facility\u0026rsquo;s performances related to six packages: healthy lifestyle, evidence-based treatment protocols; access to essential medicines and basic technology; risk-based management; team based care and task-sharing; and systems for monitoring.\u003c/p\u003e \u003cp\u003eWe assessed BP measurement practices, healthcare provider\u0026rsquo;s adherence to treatment protocols and BP-related outcomes via record reviews. We assessed patient adherence to healthy lifestyle practice through face-to-face interview. Finally, the facility\u0026rsquo;s HEARTS package implementation was assessed using observation checklists carefully prepared according to the WHO HEARTS perspective. A total of four trained data collectors, experienced Bachelor of Science Degree nurses working on chronic follow-up units and two supervisors were participated in the data collection process\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOperational definitions\u003c/h2\u003e \u003cp\u003eHypertension: patients presented with elevated systolic blood pressure (SBP)\u0026thinsp;\u0026ge;\u0026thinsp;140mmHg and/or diastolic blood pressure (DBP)\u0026thinsp;\u0026ge;\u0026thinsp;90mmHg were considered as hypertensive (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eControlled BP: hypertensive patients who had achieved two successive BP readings of SBP\u0026thinsp;\u0026lt;\u0026thinsp;140 mmHg and DBP\u0026thinsp;\u0026lt;\u0026thinsp;90mmHg were considered to have controlled BP (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData quality control\u003c/h2\u003e \u003cp\u003eThe questionnaire was pre-tested on 5% of the participants in the similar setup for its clarity, completeness and consistency. Data collectors were trained for three days regarding to data collection procedures and on how to safeguard data confidentiality during and after collection. Patient related questionnaire was translated into local language, Amharic then back to original English version. To account incomplete data, data collection tool was carefully designed in order to able to capture all relevant variables from the records. Finally, we employed completed case analysis for missing data, and cases having\u0026thinsp;\u0026gt;\u0026thinsp;5% missing values were excluded from analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were checked for completeness and consistency, coded, cleaned and analyzed using SPSS version 25.0. Descriptive statistics such as mean, standard deviations, median, interquartile range (IQR), proportions, tables and figures were used to summarize result. The independent t-test was performed to compare mean differences in performances of pilot and non-pilot facilities. Similarly, chi-square test was applied to depict association of HEARTS implementation between pilot and non-pilot facilities as well as BP control between pilot and non-pilot health facilities. Statistically, results were compared using p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 and 95% CI.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The study was approved by the Institutional Review Board of Amhara Public Health Institute (APHI) reference number NoH/R/T/T/D/5/21. Support letter was obtained from APHI, Hospitals and District Health Offices. The informed oral consent was obtained from each participant before commencement of the study. Data were de-identified, de-linked and stored in a secure file cabinet.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eStudy characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis evaluation included eight primary health facilities; four pilots and four non-pilots from two Administrative Zones and one Metropolitan City in the Amhara region. For treatment and control domains, of 474 hypertensive patient-chart pairs involved in the study in each stratum, 422 in pilot facilities and 415 in non-pilot facilities met the inclusion criteria, response rate, 89% and 87.6% respectively. The median age of patients was 56 years, IQR 47-66 years in pilot facilities and 55 years, IQR 46-64 years in non-pilot facilities. Nearly half 421(50.3%) were females (Data not shown)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe HEARTS Technical Packages implementation \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthy Life style\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll pilot (4/4) and all non-pilot (4/4) facilities had incorporated healthy lifestyle counseling practice into routine healthcare and used a standardized healthy lifestyle counseling tool. Half (2/4) of pilot and none (0/4) of non-pilot facilities had incorporated a routine NCD-related health education program in the morning sessions (Table 1) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidence-based treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll (4/4) pilot and none (0/4) of non-pilot facilities utilize the WHO\u0026rsquo;s hypertension diagnosis and treatment guideline. All pilot (4/4) and half (2/4) of non-pilot facilities use a standard case definition of hypertension. Furthermore, all (4/4) pilot facilities and none (0/4) of non-pilot utilize the major NCD treatment guidelines of Ethiopia (Table 1) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability and affordability of core antihypertensive medications and\u003c/strong\u003e \u003cstrong\u003etechnologies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll (4/4) pilot and all (4/4) non-pilot facilities ensured the availability of essential anti-hypertensive medicines. Half of (2/4) pilot facilities and quarter of (1/4) non-pilot facilities were equipped with essential technologies including BP measuring apparatus and basic laboratory tests like renal function test, complete blood count, and lipid profile (Table 1) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk-based management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll pilot (4/4) and non-pilot facilities had incorporated CVD risk monitoring indicators in their reporting form as: low risk (\u0026lt; 10%), moderate risk (10-20%), high risk (20-30%) and very high risk (\u0026ge; 30%). The system to predict a 10-year CVD risk of a patient also existed in half of pilot and quarter of non-pilot facilities. The CVD risk treatment threshold was clearly indicated and delineated in all facilities (Table 1) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeam care and task-sharing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn half of pilot and non-pilot facilities, physicians initiate, refill, and update anti-hypertensive medications, assess the CVD risk and decide next appointment while non-physician health workers counsel patients, document relevant records, and compile and report data. Hypertension care was decentralized to the community level in all pilot facilities. Health extension workers were actively involved in lost to follow-up tracing and resuming care (Table 1) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e Systems for monitoring \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll pilot and non-pilot facilities had clear indicators to monitor BP control trends at three, six, 12, 24 and 36 months. However, all pilot and non-pilot facilities neither did analyzed the routine data nor did use it for action and response (Table-1) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHypertension prevention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll (4/4) pilot and one-fourth of non-pilot facilities had incorporated the opportunistic BP screening practice for adults\u0026rsquo; \u0026ge; 30 years in the routine care. Three hundred eighty four (91%) of individuals in pilot facilities were screened thier BP 95% CI: 87.8\u0026ndash;93.5%, which is significantly higher when compared to non-pilot facilities 314 (75.7%), 95% CI: 71.2\u0026ndash;79.7%. One in five (19.9%), 95% CI: 16.2\u0026ndash;24% of individuals screened for hypertension in pilot facilities and 14.9%, 95% CI: 11.7\u0026ndash;18.6% in non-pilot facilities were confirmed to have hypertension (Figure 2) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHypertension treatment \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial antihypertensive medications were prescribed according to WHO protocol for 321 (76.1%), 95% CI: 71.7\u0026ndash;80.1% of patients in pilot facilities and 295 (71.3%), 95% CI: 66.6\u0026ndash;75.6% in non-pilot facilities, with a statistically significant difference in the protocol adherence between facilities. Likewise, there was a statistically significant difference in anti-hypertensive treatment intensification for patients between pilot facilities 349 (82.7%) 95% CI: 78.7\u0026ndash;86.2% and non-pilot facilities 330 (77.8%) 95% CI: 73.5\u0026ndash;81.7%. Moreover, patients in pilot facilities had better understanding of anti-hypertensive therapy (98.3% vs 96.1%) and its treatment target (59.5% vs 42%), chi-square test, p \u0026lt; 0.05 (Table 2) \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHypertension control\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree hundred fifty four (83.9%) of hypertensive patients in pilot facilities had reported never use of tobacco 95% CI: 80\u0026ndash;87.3%, with no a statistically significant difference among patients in non-pilot health facilities 350 (84.5%), 95% CI: 80.7\u0026ndash;87.9%. However, there was a statistically significant difference in avoidance of alcohol among patients in pilot facilities 345 (81.8%), 95% CI: 77.7\u0026ndash;85.3% and those in non-pilot facilities 319 (77.1%), 95% CI: 72.7\u0026ndash;81%. Moreover, the rate of BP control was better in pilot facilities 219 (51.9%), 95% CI: 47\u0026ndash;56.8% than non-pilot facilities 179 (42.4%) 95% CI: 37.7\u0026ndash;47.3% (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEffectiveness of hypertension prevention, treatment and control efforts\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe pilot facilities demonstrated better implementation of the WHO HEAERTS package than non-pilot facilities (75% vs 50.9%), chi-square test, X\u003csup\u003e2\u003c/sup\u003e=37.4; p \u0026lt; 0.001. The corresponding hypertension prevention, treatment and BP control performances among pilot and non-pilot facilities were 72.8%, 85.3% and 49.8%, and 43.6%, 55% and 42.7%, respectively. There was a statistically significant difference in mean performances of three domains between pilot and non-pilot facilities (76% vs 51.2%) t-test, t=2.13; p=0.042. Furthermore, pilot facilities demonstrated better BP control than non-pilot facilities, chi-square, X\u003csup\u003e2\u003c/sup\u003e=0.823; p \u0026lt; 0.001 (Table 3). \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe followed a parallel evaluation design to describe hypertension prevention, treatment and control efforts of four pilot and four non-pilot primary healthcare facilities in the Amhara region of Ethiopia and ascertain the effectiveness of pilot hypertension program.\u003c/p\u003e \u003cp\u003ePilot facilities demonstrated better implementation of the WHO HEARTS package than non-pilot facilities, chi-square test, X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;37.4; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. This could be explained by the fact that pilot facilities have received additional support, funding, and assistance from partners which could help the implementation of HEARTS packages. Additionally, pilot facilities may have benefited from a more supportive policy and regulatory environment for hypertension management.\u003c/p\u003e \u003cp\u003eThe opportunistic BP screening was higher in pilot facilities than non-pilot facilities, chi-square test, X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;37.4; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Likewise, a significant difference was observed in hypertension case detection rates between facilities. Pilot facilities identified 19.9% of hypertensive cases, 95% CI: 16.2\u0026ndash;24.0%, which is higher than hypertensive cases identified in non-pilot facilities 14.9%, 95% CI: 11.7\u0026ndash;18.6%. Hypertension case detection rate in this study was consistent with findings from the opportunistic BP screening conducted in Coastal Karnataka (20.2%) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and India (17.9%) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, it was lower than the findings from the opportunistic BP screening conducted in Nigeria (50.5%) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and Hong Kong (27.8%) (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Furthermore, retention of hypertensive patients into care was higher in non-pilot facilities (92.8%) than non-pilot facilities (86.4%). This could be due to; pilot facilities may have more trained and dedicated staff in patient counseling and have better systems for patient tracking.\u003c/p\u003e \u003cp\u003eThe BP control rate was significantly higher in pilot facilities (51.8%) compared to non-pilot facilities (42.4%). The difference in BP control between facilities could be attributed due to difference in the WHO HEARTS package implementation. This result from pilot facilities showed that pilot facilities had achieved the milestone of Ethiopia\u0026rsquo;s pilot program i.e. achieving a 50% BP control. Moreover, BP control in this study was consistent with BP control in Ayder Comprehensive Hospital 52.5% (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) and Kenya 51.7% (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), lower than BP control in Canada 66% and USA 53% (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), and higher than BP control in SSA 8% (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), China 15% (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and Italy 22.7% (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The differences might be attributed by the difference in the study design and data collection, health system and socio-demographic and clinical characteristics of patients across different settings.\u003c/p\u003e \u003cp\u003eOverall, in the present evaluation, pilot facilities demonstrated better performances across the three domains t-test, t\u0026thinsp;=\u0026thinsp;2.125; p\u0026thinsp;=\u0026thinsp;0.042. This could be explained by the fact that pilot facilities may have benefited from a more supportive policy and regulatory environment which ensures better access to essential medicines and basic diagnostics; and might have staffed with more trained health work force dedicated to facility\u0026rsquo;s goals to hypertension prevention, treatment and control compared to non-pilot facilities.\u003c/p\u003e \u003cp\u003eAlthough this study had tried to better describe pilot program in the Amhara region through a parallel evaluation design, it has the following limitations. First, as this study was subject to Training Programs for Epidemiology and Public Health Interventions Network (TEPHINET) non-research proposal reminder, the data collection did not include detailed socio-demographic characteristics and other personal identifiable information. Hence, it did not examine the potential socio-demographic factors affecting BP-related outcomes. Second, the study is merely descriptive and quantitative. There is need for integration of qualitative approaches for better understanding potential impacts of pilot program in facility\u0026rsquo;s hypertension prevention, treatment and control effort\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe pilot facilities demonstrated better performances in hypertension prevention, treatment, and control than non-pilot facilities. The mean performance across all the three domains was 76.1% in pilot facilities and 51.2% in non-pilot facilities (p\u0026thinsp;=\u0026thinsp;0.042). The pilot facilities showed better opportunistic BP screening (91% vs 74.4%) and hypertension case retention (92.8% vs 86.4%) than non-pilot facilities (74.4%). Pilot health facilities achieved a 51.8% BP control rate, which is significantly higher than non-pilot facilities (42.4%) p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The BP control rate in pilot facilities was consistent with other programs in Ethiopia, but lower than findings from high-income countries. The better performances of pilot facilities might be explained by a more comprehensive implementation of the WHO HEARTS packages including structured lifestyle counseling, evidence-based treatment protocols, improved availability of essential medications and technologies, and effective systems for team-based care and monitoring\u003c/p\u003e \u003cp\u003eWith these findings, we recommend that, a pilot hypertension program in the Amhara region of Ethiopia should be scaled up into nationwide so that the successful components of pilot program such as structured approach to hypertension management, protocol adherence, and integration of hypertension service into primary healthcare should be replicated if resources are available.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBP blood pressure;\u0026nbsp;APHI:\u0026nbsp;Amhara Public Health Institute;\u0026nbsp;CVDs: cardiovascular diseases;\u003c/p\u003e\n\u003cp\u003eDBP: diastolic blood pressure;\u0026nbsp;ETB: Ethiopian Birr;\u0026nbsp;HEARTS: healthy lifestyle, evidence-based treatment protocols; access to essential medicines and basic technology; risk-based management; team based care and task-sharing; and systems for monitoring; HICs: high income countries; IQR:\u0026nbsp;interquartile range;\u0026nbsp;LMICs: low-and-middle income countries; NCDs:\u0026nbsp;Non-communicable diseases;\u0026nbsp;RTSL: Resolve to save lives; SBP: systolic blood pressure; SSA: Sub-Saharan Africa;\u003c/p\u003e\n\u003cp\u003eTEPHINET:\u0026nbsp;Training Programs for Epidemiology and Public Health Interventions Network;\u003c/p\u003e\n\u003cp\u003eUSD: United States Dollar; WHO: World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Review Board of Amhara Public Health Institute reference number NoH/R/T/T/D/5/21. The study also obtained informed oral consent from each participant before commencement of the study\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data sets and/or analyzed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe study was supported by grant, cooperative agreement or memorandum of agreement funded by the CDC foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of Abbott, the Task Force for Global health, Inc. or TEPHINET.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbiyie Demelash conceived the research idea, designed and conducted the study, analyzed the data, and drafted the manuscript. Dawit Zenebe provided substantial contributions to design of the study and drafting the article; Alefech Addisu conducted an extensive manuscript review and structuring. Aman Yesuf provided technical support during data analysis and interpretation, and drafting the manuscript. \u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eAuthors would like to acknowledge TEPHINET, cardiovascular disease small grant program for funding this study; Mekelle University, Ethiopian Field Epidemiology Training Program and Amhara Public Health Institute for their own contributions in fulfilling the legal and ethical procedures to conduct this study. We also like to thank Dr. Thompson-Paul from the Centers for Disease Prevention and Control Mentor for her continued guidance and mentoring of the study, and data collectors and supervisors participated in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Hypertension Key facts, 16 March 2023. 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Tracing Africa\u0026rsquo;s progress towards implementing the Non-Communicable Diseases Global action plan 2013\u0026ndash;2020: a synthesis of WHO country profile reports. BMC Public Health. 2017;17:1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHEARTS Technical package for cardiovascular disease management in primary health care World Health Organization. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.who.int\u003c/span\u003e\u003cspan address=\"http://www.who.int\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed on 30 May 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrieden TR, Jaffe MG. Saving 100 million lives by improving global treatment of hypertension and reducing cardiovascular disease risk factors. J Clin Hypertens. 2018;20(2):208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization office of Africa. Ethiopia sets to improve hypertension prevention and control at primary health care level, August 16. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.afro.who.int/news/ethiopia-sets-improve-hypertension-prevention-and-control-primary-health-care-level\u003c/span\u003e\u003cspan address=\"https://www.afro.who.int/news/ethiopia-sets-improve-hypertension-prevention-and-control-primary-health-care-level\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSample Size calculation for Comparative Study [Internet]. Available from at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rnoh.nhs.uk/sites/default/files/sample_size_formula_for_a_comparative_study.pdf\u003c/span\u003e\u003cspan address=\"https://www.rnoh.nhs.uk/sites/default/files/sample_size_formula_for_a_comparative_study.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL et al. Harrison's principles of internal medicine. 21st edition. ed. New York: McGraw Hill; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdisa L, Girma S, Lami M, Hiko A, Yadeta E, Geneti Y, et al. Uncontrolled hypertension and associated factors among adult hypertensive patients on follow-up at public hospitals, Eastern Ethiopia: A multicenter study. SAGE Open Med. 2022;10:20503121221104442.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao CR, Kamath VG, Shetty A, Kamath A. High blood pressure prevalence and significant correlates: a quantitative analysis from coastal karnataka, India. Int Sch Res notices. 2013;2013(1):574973.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMenti A, Kalpourtzi N, Gavana M, Vantarakis A, Voulgari PV, Hadjichristodoulou C, et al. Opportunistic screening for hypertension: what does it say about the true epidemiology? J Hum Hypertens. 2022;36(4):364\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlaniran O, Ogunleye OO, Ojomu F. Opportunistic Screening for Hypertension, Over-weight and Obesity among Companions of Patients Attending the Family Medicine Clinic of a Nigerian Tertiary Hospital. J Hypertens Manag. 2020;6:045.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi JT, Lam AS, Tomlinson B, Lee VW, May Measurement. Month 2017\u0026ndash;2019: A Community-Wide Opportunistic Blood Pressure Screening Campaign in Hong Kong. Int J Hypertens. 2021;2021(1):8891794.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed SF, Mutua MK, Wamai R, Wekesah F, Haregu T, Juma P, et al. Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya. BMC Public Health. 2018;18:1\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoffres M, Falaschetti E, Gillespie C, Robitaille C, Loustalot F, Poulter N, et al. Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study. BMJ open. 2013;3(8):e003423.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSorato MM, Davari M, Kebriaeezadeh A, Sarrafzadegan N, Shibru T, Fatemi B. Reasons for poor blood pressure control in eastern sub-Saharan Africa: looking into 4P\u0026rsquo;s (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review. BMC Cardiovasc Disord. 2021;21:1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang X, Liu L, Song Y, Gao L, Zhao M, Bao H, et al. Achieving blood pressure control targets in hypertensive patients of rural China\u0026ndash;a pilot randomized trial. Trials. 2020;21:1\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTocci G, Ferrucci A, Pontremoli R, Ferri C, Rosei EA, Morganti A, et al. Blood pressure levels and control in Italy: comprehensive analysis of clinical data from 2000\u0026ndash;2005 and 2005\u0026ndash;2011 hypertension surveys. J Hum Hypertens. 2015;29(11):696\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: The WHO HEARTS package implementation among pilot and non-pilot facilities in Amhara region\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"637\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSub-domains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIndicators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.896389324960754%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePilot facilities (N=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.664050235478808%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNon-pilot facilities (N=4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.428571428571427%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.80952380952381%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19047619047619%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eHealthy Life style\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" valign=\"top\"\u003e\n \u003cp\u003eHealthy lifestyle counseling\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.47723704866562%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.419152276295133%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.361067503924646%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eStandardized counseling tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eNCD-related health education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eThree month lifestyle adoption\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eEvidence-based treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension treatment protocol \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.47723704866562%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.419152276295133%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.361067503924646%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eNational hypertension guideline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eStandard BP measurement protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eMajor NCD treatment guideline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eCase definition of hypertension\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension cohort register\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eAvailability and affordability of core antihypertensive medications and technologies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" valign=\"top\"\u003e\n \u003cp\u003eEssential anti-hypertensive drugs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.47723704866562%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.419152276295133%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.361067503924646%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eavailability, accessibility \u0026nbsp;and affordability\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eBasic technologies and diagnostics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eSystem to monitor essential drugs, basic technologies and diagnostics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eRisk-based management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" valign=\"top\"\u003e\n \u003cp\u003eCVD risk stratification matrix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.47723704866562%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.419152276295133%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.361067503924646%\" valign=\"top\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eCVD risk monitoring indicators\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eCVD risk treatment threshold\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003e10 year CVD risk prediction chart\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eReferral system for intensive care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eTeam based care and task-sharing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" valign=\"top\"\u003e\n \u003cp\u003eInter-professional treatment team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.47723704866562%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.419152276295133%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.361067503924646%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Delineated responsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Decentralized hypertension care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.82103610675039%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSystems for monitoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.61852433281005%\" valign=\"top\"\u003e\n \u003cp\u003eElectronic data monitoring system\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.47723704866562%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.419152276295133%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.361067503924646%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.30298273155416%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eCVD monitoring indicators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eRoutine data analysis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.397590361445786%\" valign=\"top\"\u003e\n \u003cp\u003eUse of data for action and response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.843373493975903%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.048192771084338%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.25301204819277%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.457831325301205%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable-2: Hypertension treatment and control efforts among pilot and non-pilot facilities, Amhara region, Northern Ethiopia, 2022 \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.618066561014263%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDomains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.57527733755943%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIndicators\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.4770206022187%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePilot facilities (N=422)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.329635499207605%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eNon-pilot facilities (N=415)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency (percent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.615384615384617%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.076923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eFrequency (percent)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.23076923076923%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.618066561014263%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eHypertension treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.57527733755943%\" valign=\"top\"\u003e\n \u003cp\u003eInitial medicines \u0026nbsp;prescribed as protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.263074484944532%\" valign=\"top\"\u003e\n \u003cp\u003e321 (76.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e71.7\u0026ndash;80.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.263074484944532%\" valign=\"top\"\u003e\n \u003cp\u003e296 (70.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.066561014263076%\" valign=\"top\"\u003e\n \u003cp\u003e66.6\u0026ndash;75.6%.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eMedications intensified as per protocol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e349 (82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e78.7\u0026ndash;86.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e322 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e73.5\u0026ndash;81.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eReceived all medicines in last visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e401 (95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e92.5\u0026ndash;96.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e403 (97.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e95.3\u0026ndash;98.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eCorrect understanding of medication intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e415 (98.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e96.6\u0026ndash;99.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e398 (96.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e93.8\u0026ndash;97.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eKnow thier current BP\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e289 (68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e63.8\u0026ndash;72.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e273 (65.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e61.2\u0026ndash;70.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eKnow target blood BP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e251 (59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e54.6\u0026ndash;64.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e174 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e37.2\u0026ndash;46.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eAware of next follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e410 (97.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e95.1\u0026ndash;98.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e403 (97.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e95\u0026ndash;98.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.618066561014263%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eHypertension control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.57527733755943%\" valign=\"top\"\u003e\n \u003cp\u003eAvoids tobacco smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.263074484944532%\" valign=\"top\"\u003e\n \u003cp\u003e354 (83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.213946117274167%\" valign=\"top\"\u003e\n \u003cp\u003e80\u0026ndash;87.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.263074484944532%\" valign=\"top\"\u003e\n \u003cp\u003e350 (84.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.066561014263076%\" valign=\"top\"\u003e\n \u003cp\u003e80.7\u0026ndash;87.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eAvoids alcohol use\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e345 (81.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e77.7\u0026ndash;85.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e319 (77.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e72.7\u0026ndash;81.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003eEngages in exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e115 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e23.1\u0026ndash;31.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e113 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e23.1\u0026ndash;31.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003ePractice healthy diet\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e273 (64.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e59.9\u0026ndash;69.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e263 (63.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e58.7\u0026ndash;68.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.851063829787233%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;BP control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e219 (51.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.02127659574468%\" valign=\"top\"\u003e\n \u003cp\u003e47\u0026ndash;56.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.957446808510639%\" valign=\"top\"\u003e\n \u003cp\u003e179 (42.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.21276595744681%\" valign=\"top\"\u003e\n \u003cp\u003e37.7\u0026ndash;47.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3\u003cstrong\u003e:\u003c/strong\u003e Comparison of hypertension prevention, treatment and control among\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003epilot and non-pilot facilities\u0026nbsp;in Amara region\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.77319587628866%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSub domains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIndicators\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003ePilot facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003eNon-pilot facilities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003echi square test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003et- test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"52%\" valign=\"top\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"48%\" valign=\"top\"\u003e\n \u003cp\u003eScore\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eHEARTS Implementations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eHealthy Life style\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e60%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e=37.4\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP \u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" rowspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eEvidence-based treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e79.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e33.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eessential medications and technologies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e93.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e68.8%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eRisk-based management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e60%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eTeam based care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e66.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e33.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eSystems for monitoring \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Mean score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e75 \u0026plusmn; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e50.9 \u0026plusmn; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.52577319587629%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eHypertension prevention, treatment and control\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.77319587628866%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension prevention\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e72.8 \u0026plusmn; 25.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e43.6\u0026plusmn; 51.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;t=2.125\u003c/p\u003e\n \u003cp\u003eP=\u003csup\u003e\u0026nbsp;\u003c/sup\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e85.3\u0026plusmn; 18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e55\u0026plusmn; 42.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension control\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e49.8\u0026plusmn; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e42.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.3728813559322%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Mean score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.254237288135593%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.033898305084747%\" valign=\"top\"\u003e\n \u003cp\u003e76.1 \u0026plusmn; 22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.338983050847457%\" valign=\"top\"\u003e\n \u003cp\u003e51.2\u0026plusmn; 42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hypertension prevention, hypertension treatment, hypertension control, pilot health facilities, hypertension program evaluation, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4686558/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4686558/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWith increasing trends of hypertension, Ethiopia has been piloting hypertension program whose effectiveness was not ascertained yet. Therefore, this study aimed to determine effectiveness of pilot hypertension program in the Amhara region of Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe followed a parallel evaluation design to describe hypertension prevention, treatment and control efforts of four pilot and four non-pilot facilities in Amhara region from April 1\u0026ndash;30, 2022. We used checklist with a structured questionnaire to collect data from record reviews, patient interviews and observations. Data were analyzed using SPSS version 25.0. The statistical comparison was made using chi-square test, t-test, 95% CI and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003ePilot facilities demonstrated better performances in hypertension prevention (72.8% vs 43.6%), hypertension treatment (85.3% vs 55.0%) and hypertension control (49.8% vs 42.4%) domains. The rate of opportunistic blood pressure (BP) screening was higher in pilot facilities (91%) 95% CI: 87.8\u0026ndash;93.5% than non-pilot facilities (74.4%), 95% CI: 71.2\u0026ndash;79.7%. There was a statistically significant difference in hypertension detection rates between pilot facilities (19.9%), 95% CI: 16.2\u0026ndash;24.0%) and non-pilot facilities (14.9%), 95% CI: 11.7\u0026ndash;18.6%. Half (51.8%) of hypertensive patients in pilot and 42.4% in non-pilot facilities had controlled thier BP with a statistically significant difference between facilities, chi-square, X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.823; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The mean performances across three domains was better in pilot facilities than non-pilot facilities (76.1% vs51.2%), t-test, t\u0026thinsp;=\u0026thinsp;2.125; p\u0026thinsp;=\u0026thinsp;0.042.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ethe evaluation of the pilot hypertension program in the Amhara region of Ethiopia has demonstrated promising results. Pilot facilities showed better performances across the three domains. They demonstrated better opportunistic BP screening, case detection and retention into care, and BP control compared to non-pilot facilities. Based on these findings, pilot hypertension program in the Amhara region should be scaled up into nationwide program and the successful components pilot program such as structured approach to hypertension management, protocol adherence, and integration of hypertension service into primary healthcare should be replicated.\u003c/p\u003e","manuscriptTitle":"Comparative Evaluation of Hypertension Prevention, Treatment and Control Efforts among Pilot and Non-pilot Health Facilities in Amhara Region, Northern Ethiopia, 2022: a Parallel Evaluation Design","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-10 12:28:05","doi":"10.21203/rs.3.rs-4686558/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4b9c92b-dee1-48ea-b3bf-f1c0d5da363c","owner":[],"postedDate":"August 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-22T12:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-10 12:28:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4686558","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4686558","identity":"rs-4686558","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}